Pituitary and Adrenal Disorders -...

1Elsevier items and derived items © 2007, 2006 by Saunders, an imprint of Elsevier, Inc.

Chapter 44

Pituitary and Adrenal Disorders


Learning Objectives• Identify data to be collected for the nursing assessment

of adrenal and pituitary function.• Describe the tests and procedures used to diagnose disorders of

the adrenal and pituitary glands.• Describe the pathophysiology and medical treatment of

adrenocortical insufficiency, excess adrenocortical hormones, hypopituitarism, diabetes insipidus, and pituitary tumors.

• Assist in developing nursing care plans for patients withselected disorders of the adrenal and pituitary glands.


Hormone Functions and Regulation

• Released in response to body’s needs • Responsible for reproduction, fluid and

electrolyte balance, host defenses, responses to stress and injury, energy metabolism, and growth and development

• Endocrine system: maintain homeostasis • Maintenance of physiologic stability despite

constant changes in the environment


Hormone Functions and Regulation

• Feedback mechanisms • Controls regulation of endocrine activity by either

stimulating or inhibiting hormone synthesis and secretion

• Triggered by blood levels of specific substances • May be positive or negative


The Pituitary Gland


Health History

• Present illness• Slowed or accelerated growth, visual disturbances, headache,

and changes in urine output, appearance, skin, and secondary sex characteristics

• Past medical history• Brain tumors, pituitary surgery, head trauma, central nervous

system infection, vascular disorders, chronic renal failure, hypothyroidism, and disease of the pancreas, liver, or bone

• Family history of diabetes insipidus


Health History

• Review of systems• Fatigue, weakness, restlessness, or agitation • Skin moisture and changes in body hair distribution • Significant sensory changes such as blurred vision

and diplopia (double vision) • Changes in the breasts • Chest pain, constipation, polyuria, changes in

genitalia, sexual dysfunction, joint pain, abnormal sensations, edema, seizures, and intolerance of heat or cold


Health History

• Functional assessment• Determine whether the patient has had sleep

disturbances • Usual diet; note the effects of symptoms on the

person’s self-concept and usual activities


Physical Assessment• Vital signs, height, and weight • Skin for moisture and edema • Inspect head and face for thickened lips, broad nose, and

prominent forehead and jaw; test visual acuity • Inspect the breasts for enlargement in men, atrophy in women,

and nipple discharge • Inspect and palpate the extremities for edema. Perform joint range

of motion, noting any limitations or crepitus • Test reflexes for slowness of response • Male genitalia loss of hair; palpate for testicular atrophy


Age-Related Changes

• In healthy older adults, pituitary function remains adequate

• Increased ADH secretion impairs ability to concentrate urine, increasing risk of dehydration


Diagnostic Tests and Procedures

• Radiographic studies• Conventional radiographs• Computed tomographic (CT) scans• MRI • Cerebral angiography

• Laboratory studies• Radioimmunoassay• Enzyme-linked immunosorbent assay (ELISA)• Hormone reserve activity also can be measured using a

number of “suppression” or “stimulation” tests


Disorders of the Pituitary Gland


Figure 44-2


Hyperpituitarism

• Etiology• Pathologic state caused by excess production of

one or more of the anterior pituitary hormones • Common factor is presence of a pituitary adenoma• Growth hormone and prolactin often in excess

• Overproduction leads to gigantism or acromegaly • Overproduction of prolactin causes prolactemia


Hyperpituitarism

• Medical diagnosis• Radiographic studies

• CT scans using a water-soluble dye • MRI

• Laboratory studies • Anterior pituitary hormone levels• Dexamethasone suppression tests


Hyperpituitarism

• Medical treatment• Drug therapy

• Somatostatin analogs, dopamine agonists, GH receptor antagonists, and octreotide (Sandostatin)

• Radiation • Surgical management

• Hypophysectomy: surgical removal of the adenoma or of the pituitary


Figure 44-5


Hyperpituitarism

• Assessment• Gigantism/acromegaly: energy level, height/weight, vital signs,

contours of the face and skull, visual acuity, speech, voice quality, abdominal distention

• If surgery, determine what patient knows and expects

• Interventions• Disturbed Body Image• Activity Intolerance• Chronic Pain• Ineffective Therapeutic Regimen Management


Hyperpituitarism

• Postoperative nursing care• Assessment

• Neurologic status and vision must be monitored closely with particular attention to level of consciousness, pupil size and equality, and vital signs

• Intake and output• Inspect nasal packing• Signs and symptoms of infection


Hyperpituitarism

• Postoperative nursing care• Interventions

• Anxiety• Impaired Sensory Perception• Acute Pain and Impaired Oral Mucous Membrane• Risk for Injury• Excess Fluid Volume or Deficient Fluid Volume • Risk for Infection


Etiology and Pathophysiology

• Dwarfism• Inadequate secretion of growth hormone during

preadolescence• Attainment of a maximum height 40% below normal • Causes hereditary or related to damage to the anterior portion

of the pituitary gland • Panhypopituitarism

• Growth has been completed and some pathologic process impairs the function of the pituitary


Hypopituitarism

• Signs and symptoms• Depends on the stage of life which hormones are

deficient • Dwarfism

• Occurs early; person as short as 36 inches but with proportional physical characteristics

• Often have delayed or absent sexual maturation• Accelerated pattern of aging, thus shorter life span


Hypopituitarism

• Signs and symptoms• Panhypopituitarism

• Simmonds’ cachexia • Muscle and organ wasting and disruptions of both digestion

and metabolism • Absence of ACTH affects ability to cope with stress • Thyroid-stimulating hormone is depleted• Decreased pigmentation of the skin• Gonads may become atrophied


Hypopituitarism

• Medical diagnosis• Health history, physical examination, diagnostic

tests• Conventional radiographs and CT scans • Cerebral angiography • Serum levels of pituitary hormones

• Medical and surgical treatment• Deficient hormones are replaced as needed• If caused by tumor, surgery, or radiation


Hypopituitarism

• Assessment• Sense of well-being, energy level, appetite • Changes in skin texture, body temperature, hair,

and libido • Determine whether there has been difficulty carrying

out usual activities


Hypopituitarism

• Interventions• Education important: disturbances in body image,

sexual function, nutritional status, and fluid balance can be improved if patient follows the prescribed therapy

• Acknowledge patient’s feelings and encourage expression of concerns; refer to a mental health counselor if patient has difficulty dealing with the effects of the disease


• What is the purpose of radiologic testing in diagnosing pituitary disorders?

• What laboratory findings are common in pituitary disorders?


DI vs. SIADH

• Diabetes Insipidus• Low ADH levels• Inability to concentrate

urine• Large volumes of dilute

urine• Increased plasma

osmolarity• UO may be >12 L/day• Polyuria, polydipsia

• Syndrome of Inappropriate ADH secretion

• High ADH levels• Symptoms of water

intoxication• Low urine output• Decreased plasma

osmolarity


Diabetes Insipidus (DI)

• Etiology• Excessive output of dilute urine• Nephrogenic DI

• Inherited defect: renal tubules do not respond to ADH, resulting in inadequate water reabsorption

• Neurogenic DI• A defect in either the production or secretion of ADH

• Dipsogenic DI • A disorder of thirst stimulation • When patient ingests water, serum osmolality decreases, which

causes reduced vasopressin secretion


Diabetes Insipidus

• Pathophysiology• Antidiuretic hormone deficiency or inability of kidneys to

respond to ADH results in the excretion of large volumes of very dilute urine

• Signs and symptoms• Massive diuresis, dehydration, and thirst• Malaise, lethargy, and irritability

• Medical diagnosis• Health history, physical examination, and laboratory findings• 24-hour urine output of greater than 4 L of fluid


Diabetes Insipidus

• Medical treatment• Intravenous fluid volume replacement and

vasopressors often required to maintain adequate blood pressure

• Neurogenic DI• DDAVP (desmopressin acetate)• Sodium intake restricted and thiazide diuretics prescribed


Diabetes Insipidus

• Assessment• Thirst, change in urine appearance or volume, dizziness,

weakness, fainting, and palpitations • Hydration, including skin turgor, moisture of mucous

membranes, pulse rate and quality, blood pressure, and mental status

• Intake and output, daily weights, urine specific gravity • Interventions

• Deficient Fluid Volume• Activity Intolerance • Ineffective Therapeutic Regimen Management


Syndrome of Inappropriate Antidiuretic Hormone

• Etiology• Water imbalance related to an increase in ADH synthesis or

secretion, or both • Pathophysiology

• When ADH is elevated despite normal or low serum osmolality, kidneys retain excessive water

• Plasma volume expands, causing the blood pressure to rise. Body sodium is diluted (hyponatremia), and water intoxication develops



• Signs and symptoms• Weakness, muscle cramps or twitching, anorexia,

nausea, diarrhea, irritability, headache, and weight gain without edema

• When the central nervous system is affected by water intoxication, the level of consciousness deteriorates

• Patient may have seizures or lapse into a coma



• Medical treatment • Acutely ill: hypertonic saline, very slowly over 4- to

6-hour period• Restrict fluids to 800-1000 mL/day with high intake

of dietary sodium • Or administer normal saline with loop diuretics • Patients who cannot adhere to fluid restriction with

high sodium intake may be given demeclocycline or lithium carbonate



• Medical diagnosis• Laboratory tests of serum and urine electrolytes and

osmolality • Radiographic studies of brain and lungs detect

causative factors


Case Study

• A 61-year-old diabetic male was admitted to the hospital because of malaise, progressive confusion, and a tonic/clonic seizure two weeks after starting citalopram, 20 mg/day. On physical examination the patient was euvolemic and had no evidence of malignancy, cardiac, renal, hepatic, adrenal or thyroid disease. Laboratory tests results revealed hyponatremia, serum hypoosmolality, urine hyperosmolarity, and an elevated urine sodium concentration.



• Assessment• Anorexia, nausea, vomiting, diarrhea, headache, irritability,

and muscle cramps and weakness • History of cancer, pulmonary disease, nervous system

disorders, hypothyroidism, or lupus erythematosus • Note prescription drugs the patient is taking • Weight, intake and output, urine specific gravity • Palpate the skin for moisture and edema • Test muscle strength• Seizures and muscle weakness, twitching, or cramps • Describe mental status



• Interventions• Risk for Injury• Excess Fluid Volume • Ineffective Therapeutic Regimen Management


The Adrenal Glands


Anatomy and Physiology

• A pair of small, highly vascularized triangular-shaped organs

• Located in the retroperitoneal cavity on the superior poles of each kidney, lateral to the lower thoracic and upper lumbar vertebrae

• Each weighs about 4 g and measures 3.3 cm • Two parts: an outer portion called the cortex and an

inner portion called the medulla


Function of the Adrenal Glands

• Mineralocorticoids• Produced by the zona glomerulosa• Key in maintaining adequate extracellular fluid volume

• Renin, angiotensin, and aldosterone• Renin produced by juxtaglomerular cells of renal afferent

arterioles • Release stimulated by decrease in extracellular fluid volume

• Renin acts on plasma proteins to release angiotensin I, which is catalyzed in the lung to angiotensin II

• Angiotensin II stimulates the secretion of aldosterone, which results in sodium and water retention



• Glucocorticoids• Produced by the zona reticularis and zona fasciculata • Most abundant and potent is cortisol • 92% of circulating cortisol bound to a plasma protein • Cortisol has a permissive effect on other physiologic

processes: the glucocorticoid must be present for other processes, such as catecholamine activity and excitability of the myocardium, to occur

• Control of carbohydrate, lipid, and fat metabolism, regulation of anti-inflammatory and immune responses, and control of emotional states



• Sex hormones• Adrenal androgens: class of steroids produced in the zona

fasciculata and zona reticularis • Primary function is masculinization• Other sex hormones: estrogen and progesterone

• In men, these contribute little to reproductive maturation • In women, however, estrogens are supplied by the ovaries and

adrenal glands • In postmenopausal women, the adrenal cortex is the primary

source of endogenous estrogen


Health History

• Present illness• Decreased energy, mental changes (depression, anxiety,

nervousness, confusion), sexual dysfunction, gastrointestinal disturbances, and abnormal skin pigmentation

• Past medical history• Significant aspects: radiation to the head or abdomen,

intracranial surgery, recent and current medications • Tuberculosis is the most common cause of primary adrenal

insufficiency


Health History

• Review of systems• Patient’s perception of his/her general state of health • Changes in skin color, especially bronzed or smoky

pigmentation, and increased facial hair in women. Note changes in weight and appetite

• Headache, lightheadedness with position changes, muscle weakness, nausea, vomiting, abdominal pain, anorexia, menstrual dysfunction, erectile dysfunction

• Functional assessment• Usual diet and activity patterns; disruptions in lifestyle


Physical Examination• Height, weight, and vital signs • Note patient’s responses and ability to follow instructions • Skin: bronzed/smoky pigmentation, bruising, petechiae, vitiligo,

pallor • Inspect the face of the female patient for excess facial hair • Examine the oral mucous membranes for color changes • Inspect the anterior thorax for fat pads under the clavicles, and the

posterior thorax for the “buffalo hump” • Obesity of the trunk• Examine the breasts for striae and darkening of the areola • Inspect abdomen for striae; extremities for muscle wasting and

edema • Atrophy, hair loss, appropriateness for age of genitalia


Age-Related Changes

• Under normal circumstances, adrenal function remains adequate in older person

• Some decline in cortisol secretion, but this is balanced by decrease in cortisol metabolism such that blood levels remain normal

• Secretion of aldosterone and plasma renin activity decline, thus abilities to conserve sodium and adapt to position changes less efficient


Adrenal Hypofunction

• Etiology• Primary adrenal insufficiency

• Also called Addison’s disease• Destructive disease process affecting the adrenal glands;

results in deficiencies of cortisol and aldosterone • Secondary adrenal insufficiency

• A result of dysfunction of the hypothalamus or pituitary that leads to decreased androgen and cortisol production

• Aldosterone may be affected



• Pathophysiology• Insufficiency of adrenocortical steroids: defects associated

with the loss of mineralocorticoids and glucocorticoids • Impaired secretion of cortisol: decreased gluconeogenesis and

decreased liver and muscle glycogen • Signs and symptoms

• Progressive weakness, lethargy, unexplained abdominal pain, and malaise

• Skin hyperpigmentation


Case History

• A 39-year old construction worker who complains of decreased energy, impotence , and abdominal pin is being tested for Addison's’ disease. What data should the nurse collect when obtaining the patient’s history? What physiologic changes in the body result in the abnormal symptoms of Addison’s disease?



• Acute adrenal crisis (addisonian crisis)• A life-threatening emergency• From sudden marked decrease in available adrenal

hormones • Precipitating factors are adrenal surgery, pituitary

destruction, abrupt withdrawal of steroid therapy, and stress



• Acute adrenal crisis (addisonian crisis)• Manifestations include symptoms of

mineralocorticoid and glucocorticoid deficiency but are more severe: hypotension, tachycardia, dehydration, confusion, hyponatremia, hyperkalemia, hypercalcemia, and hypoglycemia

• If untreated, fluid and electrolyte imbalances can lead to circulatory collapse, cardiac arrhythmias, cardiac arrest, coma, and death



• Medical diagnosis• Laboratory studies

• Low serum and urinary cortisol level, decreased fasting glucose, hyponatremia, hyperkalemia, and increased BUN

• Urinary 17-hydroxycorticosteroids • Plasma ACTH concentration• Plasma cortisol levels

• Electrocardiogram • Radiographic studies

• Skull films, arteriograms, CT scans, and MRI



• Medical treatment• Replacement therapy with glucocorticoids and

mineralocorticoids



• Assessment• Weight loss, salt craving, nausea and vomiting,

abdominal cramping and diarrhea, muscle weakness and aches, poor stress response, decreased libido, and amenorrhea

• Pale skin with bronzed areas, emaciation, sparse body hair, poor skin turgor, hypotension, and muscle wasting



• Interventions• Ineffective Tissue Perfusion• Risk for Injury• Imbalanced Nutrition: Less Than Body

Requirements• Fatigue• Disturbed Body Image• Ineffective Management of Treatment Regimen


Adrenal Hypersecretion (Cushing’s Syndrome)

• Etiology• Production of excess amounts of corticosteroids, particularly

glucocorticoid • Overproduction: endogenous (internal) as well as exogenous

(external)• Endogenous causes: corticotropin-secreting pituitary tumors, a

cortisol-secreting neoplasm within the adrenal glands, excess secretion of corticotropin by carcinoma of the lung or other tissues

• Exogenous cause: prolonged administration of high doses of corticosteroids


Adrenal Hypersecretion (Cushing’s Syndrome): Pathophysiology

• Clinical manifestations affect most body systems; excess levels of circulating corticosteroids

• Produces marked changes in personal appearance, including obesity, facial redness, hirsutism, menstrual disorders, hypertension of varying degrees, muscle wasting of extremities

• Additionally delayed wound healing, insomnia, irrational behavior, and mood disturbances such as irritability and anxiety


Adrenal Hypersecretion (Cushing’s Syndrome): Pathophysiology

• Findings that lead to diagnosis• Truncal obesity • Protein wasting • Facial fullness, often called a “moon face”• Purple striae on the abdomen, breasts, buttocks, or

thighs• Osteoporosis • Hypokalemia of uncertain etiology



• Medical diagnosis• Laboratory studies

• 24-hour urine collection for free cortisol • Low-dose dexamethasone suppression test• Abnormal laboratory findings: polycythemia, hypokalemia,

hypernatremia, hyperglycemia, leukocytosis, glycosuria, hypocalcemia, and elevated plasma cortisol

• Radiographic studies • CT scan and MRI



• Medical treatment• Drug therapy

• Mitotane (Lysodren), ketoconazole (Nizoral), aminoglutethimide (Cytadren), and metyrapone (Metopirone)

• Radiation • Administered externally or internally

• Surgical management



• Assessment• Detailed history and physical examination• Onset of symptoms, prior treatments, drug allergies, and

current medications • Interventions

• Risk for Infection• Disturbed Thought Processes• Risk for Impaired Skin Integrity• Risk for Injury• Disturbed Body Image• Ineffective Therapeutic Regimen Management


Preoperative Care of the Adrenalectomy Patient

• Correct any electrolyte imbalances • Strict hand washing and observance of aseptic

technique to prevent infections in these susceptible patients

• Preoperative education involves a discussion of glucocorticoid replacement therapy, including dosage, side effects, and complications


Postoperative Care of the Adrenalectomy Patient

• Vital signs for signs and symptoms of impending shock (evident as hypotension), weak or thready pulse, decreased urinary output, and changes in level of consciousness

• Pulse and blood pressure may be unstable for 24 to 48 hours after surgery; vasopressors to maintain blood pressure in immediate postoperative period


Postoperative Care of the Adrenalectomy Patient

• Protect patient by using strict aseptic technique for wound care and invasive procedures

• Assess comfort at frequent intervals, and treat pain with opioid analgesics

• Instruct the patient to turn, cough, deep breathe, or use an incentive spirometer


Adrenocortical Hormones

• Glucocorticoids (cortisone, prednisone, hydrocortisone, dexamethasone)• Use: adrenal insufficiency, allergic reactions,

collagen diseases, dermatologic disorders, rheumatic disorders, shock. Suppress inflammation

• Cautions: withdraw slowly, caution in patients with renal or hepatic disease, hypothyroidism, osteoporosis, PUD, HTN, DM

• Mineralocorticoids (fludorcortisone)• Use: partial replacement tx for Addison’s disease• Cautions: systemic fungal infection


Pheochromocytoma

• Usually benign tumor of adrenal medulla causes excessive catecholamine secretion

• Hypertension, hypermetabolism, hyperglycemia

• Episodes triggered by emotional distress, exercise, manipulation of the tumor, postural changes, and major trauma, including surgery

• Treated by surgical removal of the tumor

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